1972085769 NPI number — RIVER EDGE BEHAVIORAL HEALTH CENTER

Table of content: (NPI 1972085769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972085769 NPI number — RIVER EDGE BEHAVIORAL HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVER EDGE BEHAVIORAL HEALTH CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RIVER EDGE BOULEVARD PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972085769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 EMERY HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31217-3692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-803-7700
Provider Business Mailing Address Fax Number:
478-803-8598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
265 BOULEVARD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30312-1208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-665-8550
Provider Business Practice Location Address Fax Number:
404-665-8693
Provider Enumeration Date:
08/29/2018

Additional Information

Authorized Official

Authorized Official Last Name:
OAKES
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
478-803-7809

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHRE010434 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHRE010434 . This is a "GEORGIA PHARMACY LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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